Name
Address
City/State/Zip
Phone
E-mail
Age
Name of Your School

Current Grade Level
Current GPA
Hobbies
Favorite Subject in School

I want a student mentor.

I want an alumna mentor.

I want both.

Have you taken or are you planning to take any advanced math or science courses?
Yes No
If yes, please list.

What interests you about engineering? (For example, do you want to be an astronaut? Work to solve environmental problems? Develop new biomedical procedures or devices, etc.?)

Do you have a goal? Do you know what you want to do with your life?
Please describe your plans

Do you anticipate needing more than four years of college to reach your goal(s)?

Are you looking for a mentor with experience in a specific area, i.e.,
nanotechnology, chemical engineering, or bioengineering?    Yes     No

If yes, please list your top three areas of interest.

Are you looking for a mentor who has experience working in a lab or research setting?
Yes No

If yes, list the area of research or lab equipment/procedures you are most interested in learning more about.

How do you think having a mentor will help you achieve your goal(s)?